HL7.CDA.US.CCDA\Findings Section (DIR) - Definitions

This page is part of the CCDA: Consolidated CDA Release (v2.1.0-draft1: CCDA 2.1 Draft) generated with FHIR v5.0.0. . For a full list of available versions, see the Directory of published versions

Resource Profile: FindingsSectionDIR - Detailed Descriptions

Active as of 2023-01-16

Definitions for the 2.16.840.1.113883.10.20.6.1.2 resource profile.

Differential Elements Table
Key Elements Table
Snapshot Elements Table

Guidance on how to interpret the contents of this table can be found here.

1. Section
Invariants	Defined on this element 81-8532: This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). (: null)
2. Section.templateId
Slicing	This element introduces a set of slices on Section.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ root
3. Section.templateId:primary
SliceName	primary
Control	1..1
Requirements	SHALL contain exactly one [1..1] templateId (CONF:81-8531) such that it
4. Section.templateId:primary.root
Control	1..1
Requirements	SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.1.2" (CONF:81-10456).
Pattern Value	2.16.840.1.113883.10.20.6.1.2

Guidance on how to interpret the contents of this table can be found here.

1. Section
Definition	Base definition for all types defined in FHIR type system.
Control	10..1*
Invariants	Defined on this element 81-8532: This section SHOULD contain only the direct observations in the report, with topics such as Reason for Study, History, and Impression placed in separate sections. However, in cases where the source of report content provides a single block of text not separated into these sections, that text SHALL be placed in the Findings section (CONF:81-8532). (: null) ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
2. Section.classCode
Control	1..1
Binding	The codes SHALL be taken from ActClassRecordOrganizer
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	DOCSECT
Fixed Value	DOCSECT
3. Section.moodCode
Control	1..1
Binding	The codes SHALL be taken from ActMood
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	EVN
Fixed Value	EVN
4. Section.templateId
Definition	When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
Control	0..*
Type	http://hl7.org/fhir/cda/StructureDefinition/II
Slicing	This element introduces a set of slices on Section.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ root
5. Section.templateId:primary
SliceName	primary
Definition	When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
Control	1..1
Type	http://hl7.org/fhir/cda/StructureDefinition/II
Requirements	SHALL contain exactly one [1..1] templateId (CONF:81-8531) such that it
6. Section.templateId:primary.root
Definition	A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
Control	1..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
Requirements	SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.1.2" (CONF:81-10456).
Pattern Value	2.16.840.1.113883.10.20.6.1.2
7. Section.text
Control	0..1
Type	xhtml
Must Support	true
XML Representation	This property is represented as CDA Text in the XML.

Guidance on how to interpret the contents of this table can be found here.

1. Section
Definition	Base definition for all types defined in FHIR type system.
Control	1..1
2. Section.ID
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
3. Section.nullFlavor
Control	0..1
Binding	The codes SHALL be taken from NullFlavor
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
4. Section.classCode
Control	1..1
Binding	The codes SHALL be taken from ActClassRecordOrganizer
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	DOCSECT
Fixed Value	DOCSECT
5. Section.moodCode
Control	1..1
Binding	The codes SHALL be taken from ActMood
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	EVN
Fixed Value	EVN
6. Section.templateId
Definition	When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
Control	0..*
Type	http://hl7.org/fhir/cda/StructureDefinition/II
Slicing	This element introduces a set of slices on Section.templateId. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ root
7. Section.templateId:primary
SliceName	primary
Definition	When valued in an instance, this attribute signals the imposition of a set of template-defined constraints. The value of this attribute provides a unique identifier for the templates in question
Control	1..1
Type	http://hl7.org/fhir/cda/StructureDefinition/II
Requirements	SHALL contain exactly one [1..1] templateId (CONF:81-8531) such that it
8. Section.templateId:primary.nullFlavor
Definition	If a value is an exceptional value (NULL-value), this specifies in what way and why proper information is missing.
Control	0..1
Binding	The codes SHALL be taken from NullFlavor
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
9. Section.templateId:primary.assigningAuthorityName
Definition	A human readable name or mnemonic for the assigning authority. The Assigning Authority Name has no computational value. The purpose of a Assigning Authority Name is to assist an unaided human interpreter of an II value to interpret the authority. Note: no automated processing must depend on the assigning authority name to be present in any form.
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
10. Section.templateId:primary.displayable
Definition	Specifies if the identifier is intended for human display and data entry (displayable = true) as opposed to pure machine interoperation (displayable = false).
Control	0..1
Type	boolean
XML Representation	In the XML format, this property is represented as an attribute.
11. Section.templateId:primary.root
Definition	A unique identifier that guarantees the global uniqueness of the instance identifier. The root alone may be the entire instance identifier.
Control	1..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
Requirements	SHALL contain exactly one [1..1] @root="2.16.840.1.113883.10.20.6.1.2" (CONF:81-10456).
Pattern Value	2.16.840.1.113883.10.20.6.1.2
12. Section.templateId:primary.extension
Definition	A character string as a unique identifier within the scope of the identifier root.
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
13. Section.id
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/II
14. Section.code
Control	0..1
Binding	The codes SHALL be taken from DocumentSectionType; other codes may be used where these codes are not suitable
Type	http://hl7.org/fhir/cda/StructureDefinition/CE
15. Section.title
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/ST
16. Section.text
Control	0..1
Type	xhtml
Must Support	true
XML Representation	This property is represented as CDA Text in the XML.
17. Section.confidentialityCode
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/CE
18. Section.languageCode
Control	0..1
Binding	The codes SHALL be taken from HumanLanguage
Type	http://hl7.org/fhir/cda/StructureDefinition/CS
19. Section.subject
Control	0..1
Type	Element
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. Section.subject.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
Summary	false
21. Section.subject.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control	0..*
Type	Extension
Summary	false
Alternate Names	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Slicing	This element introduces a set of slices on Section.subject.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ url
22. Section.subject.typeCode
Control	1..1
Binding	The codes SHALL be taken from ParticipationTargetSubject
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	SBJ
Fixed Value	SBJ
23. Section.subject.contextControlCode
Control	1..1
Binding	The codes SHALL be taken from ContextControl
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	OP
Fixed Value	OP
24. Section.subject.awarenessCode
Control	0..1
Binding	The codes SHALL be taken from TargetAwareness; other codes may be used where these codes are not suitable
Type	http://hl7.org/fhir/cda/StructureDefinition/CE
25. Section.subject.relatedSubject
Control	1..1
Type	http://hl7.org/fhir/cda/StructureDefinition/RelatedSubject
26. Section.author
Control	0..*
Type	http://hl7.org/fhir/cda/StructureDefinition/Author
27. Section.informant
Control	0..*
Type	Element
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. Section.informant.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
Summary	false
29. Section.informant.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control	0..*
Type	Extension
Summary	false
Alternate Names	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Slicing	This element introduces a set of slices on Section.informant.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ url
30. Section.informant.typeCode
Control	1..1
Binding	The codes SHALL be taken from ParticipationInformationGenerator
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	INF
Fixed Value	INF
31. Section.informant.contextControlCode
Control	1..1
Binding	The codes SHALL be taken from ContextControl
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	OP
Fixed Value	OP
32. Section.informant.assignedEntity
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/AssignedEntity
33. Section.informant.relatedEntity
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/RelatedEntity
34. Section.entry
Control	0..*
Type	Element
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) only-one-statement: SHALL have no more than one of observation, regionOfInterest, observationMedia, substanceAdministration, supply, procedure, encounter, organizer or act. (: (observation \| regionOfInterest \| observationMedia \| substanceAdministration \| supply \| procedure \| encounter \| organizer \| act).count() = 1)
35. Section.entry.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
Summary	false
36. Section.entry.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control	0..*
Type	Extension
Summary	false
Alternate Names	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Slicing	This element introduces a set of slices on Section.entry.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ url
37. Section.entry.typeCode
Control	1..1
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	COMP
38. Section.entry.contextConductionInd
Control	1..1
Type	boolean
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	true
39. Section.entry.observation
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Observation
40. Section.entry.regionOfInterest
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/RegionOfInterest
41. Section.entry.observationMedia
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/ObservationMedia
42. Section.entry.substanceAdministration
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/SubstanceAdministration
43. Section.entry.supply
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Supply
44. Section.entry.procedure
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Procedure
45. Section.entry.encounter
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Encounter
46. Section.entry.organizer
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Organizer
47. Section.entry.act
Control	0..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Act
48. Section.component
Control	0..*
Type	Element
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
49. Section.component.id
Definition	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Control	0..1
Type	string
XML Representation	In the XML format, this property is represented as an attribute.
Summary	false
50. Section.component.extension
Definition	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Control	0..*
Type	Extension
Summary	false
Alternate Names	extensions, user content
Comments	There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Invariants	Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists())
Slicing	This element introduces a set of slices on Section.component.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: value @ url
51. Section.component.typeCode
Definition	Drawn from concept domain DocumentSectionType
Control	1..1
Type	code
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	COMP
Fixed Value	COMP
52. Section.component.contextConductionInd
Control	1..1
Type	boolean
XML Representation	In the XML format, this property is represented as an attribute.
Default Value	true
53. Section.component.section
Control	1..1
Type	http://hl7.org/fhir/cda/StructureDefinition/Section